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Private health licencing forms and templates

The licencing process involves compliance with various parts of the Private Health Facilities Act (1999), the Regulation (2016), and the (Standards) Notice (2016). The following supporting documents will help you provide the necessary information at each stage of a licence process.

Read about the licence types for an explanation of which forms and supporting documentation is required for each application.

Forms

Please send all correspondence and supporting documentation to Private_Health@health.qld.gov.au or post to PO Box 2368 Fortitude Valley BC 4006.

The application forms are formatted as interactive PDFs. Find help on line or contact us if you have trouble downloading or completing these forms.

Supporting documentation

Reference

Information required

Description and guidance on how to provide evidence

A

Statutory declaration

Statutory declaration to provide evidence of the character and good standing of the company director/s

Download the statutory declaration (DOC 428 kB)

B

Parent company agreement to provide financial support

Statutory declaration to confirm arrangements for financial support where the licensee is being backed by a parent company. This document is not required for an independently funded application

Download the parent company statement statutory declaration (DOC 253 kB)

C

Financial standing

Statutory declaration, completed by an independent financier or accountant to confirm the financial standing of the licensee

Download the financial standing statutory declaration (DOC 250 kB)

D

Authority holder's CV and business records

Provide:

  • CV summaries of the company director/s
  • Summary of relevant experience in owning / operating a health facility to support current application
  • Formal proof of registered office address (eg: ASICS statement of registration, Copy of Certification of Incorporation or certificate of registration certified by a Justice of the Peace)

E

Commercial / financial viability

Provide:

  • Evidence of financial stability:
    • Sole operator: budget documents (or similar) showing financial stability for the previous 2 financial years
    • Company: copy of audited financial statements for previous 2 financial years
    • If licensee is being backed by a parent company, you need to provide the parent company's records
  • Evidence of financial support, and ability to meet repayments:
    • Bank, or other institution, loan arrangements
    • Proposed financial plan / operating budget plan, including repayments schedule
    • A signed statement from the financier verifying that the entity has the financial capacity to establish and operate the facility for at least two (2) years.

Download the financial standing statutory declaration (DOC 250 kB) This information is forwarded to Veda for independent review.

F

Business plan

This evidence is only required from those applying to operate new facilities.
Provide:

  • High level statement of goals / mission statement / strategic direction, including:
    • Overview of the types of CSCF services you wish to offer
    • CMBS item number and/or ICD codes for each proposed clinical service
    • Any demographic research you may have undertaken into the need for these services in this location
  • Proposed organisation chart (including names where known)

Ga

Clinical services capability framework (CSCF):

  • List of services and levels

List of proposed services (for initial approval to build)
Indicate which services and levels you intend to offer.

Gb

Clinical services capability framework (CSCF):

  • Description of services levels

Descriptions of service levels

  • Reference the relevant Clinical Services Capability Framework (CSCF) modules—these documents provide details of the minimum requirements to offer each service at a particular level.
  • Provide a description for each service, to explain how you meet / intend to meet the requirements.

Download the description of service levels template (DOC 295 kB) (use one per service)

Download an example (DOC 305 kB)

H

Building plans

Description of the area to be licensed

Building plans (for initial approval to build)
Provide:

  • Floor plan for the new/changed facility. We require 2 sets of the plans:
    • 1:100 proposed floor plans
    • 1:200 proposed floor plans
  • Physical address details

If development is occurring in stages highlight different stages on submitted plans.
Description of the area to be licensed for subsequent applications)
This is particularly relevant where a licence only relates to parts of the premises.
Provide:

  • Simple floor plans (eg: diagram of the evacuation plan for the licensed area.

I

Management team / staffing details

Provide:

  • Chief executive officer / Manager of the facility – name and copy of current CV
  • Nurse in Charge / Director of Nursing – name, copy of current CV and current Australian Health Practitioner Regulation Agency (AHPRA) certificate of registration
  • Staffing plan – list intended service providers names and (AHPRA) registration details where applicable. (medical/surgical/allied health/core services and support staff)

J

Policies and procedures

Provide:

  • copies of the following policies and procedures that must be in place before a facility can operate:
  1. Medical emergency policy including patient transfer procedures
  2. Patient admission criteria
  3. Patient consent procedures
  4. Patient complaint procedures
  5. Infection control policy
  6. Medication management plan
  7. Quality policy
  8. Storage and collection of waste, including contaminated waste policy
  9. Risk management plan
  10. Credentialling and clinical privileges committee terms of reference and meeting minutes which includes names of members
  11. Infection Control committee meeting minutes which includes names of members
  12. Proposed staff roster for each clinical area
  13. Staff orientation program
  14. Water risk quality management plan
  15. Name of quality assurance entity, date of registration and proposed date of initial certification.

K

Audit tool – self assessment against the Queensland Private Health Facility Standards

Evidence of compliance with the Queensland Standards is provided via a self-audit checklist.
Where the facility is non-compliant, you should provide the reason, and steps in place to rectify the situation. This is all captured in the checklist.
Download the self-compliance assessment tool (DOC 504 kB)

L

Mental health Standards

This evidence is only required from those applying to offer mental health services.
Complete:

This will meet the requirements of the QueenslandPrivate Health Facilities Act 1999 (i.e. compliance with the National Standards for Mental Health Services - NSMHS) as well as assist the facility to prepare for accreditation against the National Safety and Quality Health Service Standards NSQHSS.

Please provide:

  • Copies of documentary evidence noted in the workbook
  • Outline of proposed mental health programs
Last updated: 18 September 2018

Licence types

Read about the different licence types, including the forms and corresponding supporting documentation you need to provide for each licence type.